INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 5, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide direct observation by a trained counselor or clinical supervisor for the first 3 months of employment or for the next 9 months, under close supervision.
Employee #6 was promoted on March 17, 2024 to counselor assistant and was still employed at the time of the inspection. He did not have the required documentation of direct and close supervision.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Employee #6 is no longer employed with Pyramid Quakertown as of 6/13/24. Moving forward, Facility Director will review supervisions monthly to ensure correct oversight and supervisions are taking place. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee in the required time frame, appropriate to that employee's skill level in one out of seven employee records reviewed.
Employee #4 was hired on March 11, 2024 as a counselor and was still in the position as of the date of the inspection. The plan is dated May 23, 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Development of individual training plans will be scheduled specifically into new employee onboarding schedule to ensure completion within the first 30 days. Managers will submit via Relias, as well as a tracking Smartsheet effective 6/30/24. Oversight for completion by Facility Director and Administrative Assistant. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in five out of twelve records reviewed.
Employee #8 was hired as a behavioral health technician supervisor on October 25, 2021 and was due to have the communicable disease trainings no later than October 25, 2023. There was documentation in the file that the HIV/AIDS training was completed on May 25, 2024 and there was no documentation of the TB/STD training being completed.
Employee #9 was hired as a behavioral health technician March 25, 2021 and was due to have the communicable disease trainings no later than March 25, 2023. There was documentation in the file that the HIV/AIDS training was completed on August 25, 2024 and there was no documentation of the TB/STD training being completed.
Employee #10 was hired as a behavioral health technician on October 4, 2021 and was due to have the communicable disease trainings no later than October 4, 2023. There was documentation in the file that the HIV/AIDS training was completed on October 27, 2023 and there was no documentation of the TB/STD training being completed.
Employee #11 was hired as a behavioral health technician on November 11, 2019 and was due to have the communicable disease trainings no later than November 11, 2021. There was documentation in the file that the HIV/AIDS training was completed on May 23, 2024 and there was no documentation of the TB/STD training being completed.
Employee #12 was hired as a behavioral health technician on August 16, 2021 and was due to have the communicable disease trainings no later than August 16, 2023. There was documentation in the file that the HIV/AIDS training was completed on October 16, 2023 and there was no documentation of the TB/STD training being completed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Registration and/or completion of required communicable disease trainings will be integrated into employee onboarding schedule within the first 2-3 weeks of employment. Tracking of completion certificates will be completed by employee's direct supervisor, Facility Director, and Administrative Assistant. BHT Manager and Facility Director tracking registration for all current employees, which will be completed by 12/31/2024. Smartsheet will be reviewed monthly to ensure compliance with training deadlines. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling rooms.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director to submit waiver request to licensing body due to group rooms being utilized for multiple purposes and need to monitor for client safety. Cameras to be shut down or removed from group rooms during group therapy times pending results of waiver request. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of inpatient client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client record.
Client #5 was admitted on April 19, 2024 and discharged on May 13, 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director to review the expectation that Discharge Management Plans should be completed within 24 hours for all non-routine discharges. Additionally, Facility Director will review expectation that the discharge letter is provided to each client at the time of discharge or sent to the client post-discharge if unable to provide to the client at discharge. This supervision will take place on 7/2/24. Facility Director and Clinical Supervisor will track completion of the discharge management plans as well as the discharge letters beginning 7/1/2024 via review in morning meeting daily which includes the entire clinical team. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of inpatient client records, the facility failed to document a complete psychosocial evaluation according to the facilities policy and procedure of 24 hours in seven out of seven applicable records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director to review admission tracking Smartsheet monthly to ensure completion of biopsychosocial in level of care assessment completed by intake counselor. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of inpatient client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in three out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 72 hours following admission.
Client #1 was admitted on March 28, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later March 31, 2024; however, it was not completed until April 4, 2024.
Client #2 was admitted on April 10, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was due no later April 13, 2024; however, it was not completed until April 23, 2024.
Client #5 was admitted on April 19, 2024 and discharged on May 13, 2024. A comprehensive treatment plan was due no later than April 22, 2024; however, it was not completed until April 24, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Tracking Smartsheet was developed to monitor for completion of initial treatment plan within 72 hours of admission date, reviewed daily by facility director or clinical supervisor in treatment team meeting for completion with clinical staff. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of inpatient client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in six out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed within seven days following admission.
Client #1 was admitted on March 28, 2024 and was still active at the time of the inspection. A case consultation was due no later than April 4, 2023; however, it was not completed until April 17, 2024.
Client #2 was admitted on admitted on April 10, 2024 and was still active at the time of the inspection. A case consultation was due no later than April 17, 2024; however, none was completed.
Client #3 was admitted on admitted on April 19, 2024 and was still active at the time of the inspection. A case consultation was due no later than April 26, 2024; however, none was completed.
Client #5 was admitted on April 19, 2024 and was discharged on May 13, 2024. A case consultation was due no later than April 26, 2024; however, none was completed.
Client #6 was admitted on January 16, 2024 and was discharged on March 12, 2024. A case consultation was due no later than March 19, 2024; however, none was completed.
Client #7 was admitted on March 5, 2024 and was discharged on April 18, 2024. A case consultation was due no later than April 25, 2024; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Tracking Smartsheet was developed to ensure completion of admission case consultation within 7 days of client admission. Facility Director to send email to counselor on day 4 to inform counselor of the need for completion. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of inpatient client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed seven days following discharge.
Client #6 was admitted on January 16, 2024 and discharged on March 12, 2024. A follow up was due no later than March 19, 2024; however, none was completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Tracking Smartsheet was developed to track follow up calls within 7 days of discharge. Care coordinators are responsible for completion, facility director maintains oversight and updates Smartsheet weekly. |